Open Access Plus: Connecticut General Life Insurance Co.

Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual + Family | Plan Type: OAP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myCigna.com or by calling 1-800-Cigna24 Important Questions Answers For in-network providers $2,500 person / $5,000 family For out-of-network providers $10,000 person / $20,000 family Deductible per person applies when the employee is the What is the overall only person covered under the plan. deductible? Does not apply to in-network preventive care, in-network office visits, emergency room visits, urgent care facility visits, prescription drugs Co-payments don't count toward the deductible. Yes, in-network prescription drugs - $100 person / $200 Are there other deductibles family for specific services? There are no other specific deductibles. Yes. For in-network providers $5,000 person / $10,000 family / For out-of-network providers $30,000 person / Is there an out-of-pocket limit $60,000 family. on my expenses? Out-of-pocket limit for person applies when the employee is the only person covered under the plan. What is not included in the Premium, balance-billed charges, penalties for no preout-of-pocket limit? authorization, and health care this plan doesn't cover. Is there an overall annual No. limit on what the plan pays? Does this plan use a network of providers? Yes. For a list of participating providers, see www.myCigna.com or call 1-800-Cigna24 Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Important Questions Do I need a referral to see a specialist? Are there services this plan doesn't cover?

Answers No. You don't need a referral to see a specialist. Yes.

Why this Matters: You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 4. See your policy or plan document for additional information about excluded services.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Services You May Need Primary care visit to treat an injury or illness Specialist visit Your Cost if you use an In-Network Provider Out-of-Network Provider $50 co-pay/visit $50 co-pay/visit $50 co-pay/visit for chiropractor No charge No charge 30% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance Limitations & Exceptions -----------none---------------------none----------Coverage for Chiropractic services is limited to 20 days annual max. -----------none----------Deductible is waived -----------none-----------

Common Medical Event

If you visit a health care provider's office or clinic

Other practitioner office visit Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

If you have a test

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCigna.com If you have outpatient surgery

Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care

Your Cost if you use an In-Network Provider Out-of-Network Provider $20 co-pay/prescription (retail), $40 co-pay/prescription (home 50% co-insurance delivery) $40 co-pay/prescription (retail), $80 co-pay/prescription (home 50% co-insurance delivery) $70 co-pay/prescription (retail), $140 co-pay/prescription (home 50% co-insurance delivery) 30% co-insurance 30% co-insurance $100 co-pay/visit 30% co-insurance $50 co-pay/visit 30% co-insurance 30% co-insurance $50 co-pay/office visit and 30% co-insurance/other outpatient services 30% co-insurance $50 co-pay/office visit and 30% co-insurance/other outpatient services 30% co-insurance 50% co-insurance 50% co-insurance $100 co-pay/visit 30% co-insurance $50 co-pay/visit 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance

Limitations & Exceptions Coverage is limited up to a 30 day supply (retail) and up to a 90 -day supply (home delivery) Coverage is limited up to a 30 day supply (retail) and up to a 90 -day supply (home delivery) Coverage is limited up to a 30 day supply (retail) and up to a 90 -day supply (home delivery) -----------none---------------------none----------Per visit co-pay is waived if admitted -----------none----------Per visit co-pay is waived if admitted -----------none---------------------none---------------------none---------------------none---------------------none---------------------none-----------

If you need immediate medical attention

Facility fee (e.g., hospital If you have a hospital stay room) Physician/surgeon fees Mental/Behavioral health outpatient services If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Common Medical Event If you are pregnant

Services You May Need Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services

Your Cost if you use an In-Network Provider Out-of-Network Provider 30% co-insurance 50% co-insurance 30% co-insurance 30% co-insurance $50 co-pay/visit Not Covered 30% co-insurance 30% co-insurance 30% co-insurance Not Covered Not Covered Not Covered 50% co-insurance 50% co-insurance 50% co-insurance Not Covered 50% co-insurance 50% co-insurance 50% co-insurance Not Covered Not Covered Not Covered

Limitations & Exceptions -----------none---------------------none---------------------none----------Coverage for Rehabilitation services is limited to 60 days annual max. -----------none----------Coverage is limited to 90 days annual max -----------none---------------------none---------------------none---------------------none---------------------none-----------

If you need help recovering or have other special health needs

Habilitation services Skilled nursing care Durable medical equipment Hospice services Eye Exam Glasses Dental check-up

If your child needs dental or eye care

Excluded Services & Other Covered Services

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Habilitation services Bariatric surgery Hearing aids Cosmetic surgery Long-term care Routine foot care Dental care (Adult) Non-emergency care when traveling outside the U.S. Weight loss programs Dental care (Children) Private-duty nursing Eye care (Children) Routine eye care (Adult) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Infertility treatment

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Your Rights to Continue Coverage

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-Cigna24. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the New Jersey Department of Banking and Insurance at (609) 292-5316. Additionally, a consumer assistance program can help you file your appeal. Contact the program for this plan's situs state: New Jersey Department of Banking and Insurance at 800-446-7467. However, for information regarding your own state's consumer assistance program refer to www.healthcare.gov.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-----------

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Coverage Examples About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having a baby
(normal delivery) Amount owed to providers: $7,540 Plan pays: $4,210 Patient pays: $3,330 Sample care costs: Hospital charges (mother) $2,700 Routine Obstetric Care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductible Co-pays Co-insurance Limits or exclusions Total $2,600 $90 $610 $30 $3,330

Managing type 2 diabetes

(routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $3,460 Patient pays: $1,940 Sample care costs: Prescriptions $2,900 Medical equipment and supplies $1,300 Office visits & procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible Co-pays Co-insurance Limits or exclusions Total $100 $1,520 $0 $320 $1,940

This is not a cost estimator.

Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Note: These numbers assume enrollment in individual-only coverage.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?
Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or pre existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits

and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The

care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay.

Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators.

You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Plan ID: 46375 Plan Name: OAP GM5800/6000 9/23/12 Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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SUMMARYOFBENEFITS
ConnecticutGeneralLifeInsuranceCo. ForEmployeesofCollabera OpenAccessPlusPlan SelectionofaPrimaryCareProviderYourplanmayrequireorallowthedesignationofaprimarycareprovider.Youhavetherighttodesignateanyprimarycare providerwhoparticipatesinthenetworkandwhoisavailabletoacceptyouoryourfamilymembers.Ifyourplanrequiresdesignationofaprimarycareprovider, Cignamaydesignateoneforyouuntilyoumakethisdesignation.Forinformationonhowtoselectaprimarycareprovider,andforalistoftheparticipatingprimary careproviders,visitwww.mycigna.comorcontactcustomerserviceatthephonenumberlistedonthebackofyourIDcard. DirectAccesstoObstetriciansandGynecologistsYoudonotneedpriorauthorizationfromtheplanorfromanyotherperson(includingaprimarycare provider)inordertoobtainaccesstoobstetricalorgynecologicalcarefromahealthcareprofessionalinournetworkwhospecializesinobstetricsorgynecology. Thehealthcareprofessional,however,mayberequiredtocomplywithcertainprocedures,includingobtainingpriorauthorizationforcertainservices,followinga preapprovedtreatmentplan,orproceduresformakingreferrals.Foralistofparticipatinghealthcareprofessionalswhospecializeinobstetricsorgynecology,visit www.mycigna.comorcontactcustomerserviceatthephonenumberlistedonthebackofyourIDcard. Forchildren,youmaydesignateapediatricianastheprimarycareprovider.

PlanHighlights
LifetimeMaximum Coinsurance Unlimited

InNetwork
Unlimited Youpay30%coinsurance

OutofNetwork

Youpay50%coinsurance

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PlanHighlights

InNetwork

OutofNetwork

MaximumReimbursableCharge OutofnetworkservicesaresubjecttoaCalendarYeardeductibleand maximumreimbursablechargelimitations.Paymentsmadetohealthcare professionalsnotparticipatinginCigna'snetworkaredeterminedbased onthelesserof:thehealthcareprofessional'snormalchargeforasimilar serviceorsupply,orapercentage(150%)ofafeescheduledevelopedby CignathatisbasedonamethodologysimilartooneusedbyMedicareto determinetheallowablefeeforthesameorsimilarserviceina geographicarea.Insomecases,theMedicarebasedfeescheduleisnot NotApplicable used,andthemaximumreimbursablechargeforcoveredservicesis determinedbasedonthelesserof:thehealthcareprofessional'snormal chargeforasimilarserviceorsupply,ortheamountchargedforthat serviceby80%ofthehealthcareprofessionalsinthegeographicarea whereitisreceived.Thehealthcareprofessionalmaybillthecustomerthe differencebetweenthehealthcareprofessional'snormalchargeandthe MaximumReimbursableChargeasdeterminedbythebenefitplan,in additiontoapplicabledeductibles,copaymentsandcoinsurance. CalendarYearDeductible l Onlytheamountyoupayforinnetworkcoveredexpensescounts towardyourinnetworkdeductible.Theamountyoupayforoutof networkcoveredexpensescountstowardbothyourinnetworkand Individual:$2,500 outofnetworkdeductibles. Family:$5,000 l Alleligiblefamilymemberscontributetowardsthefamilyplan deductible.Oncethefamilydeductiblehasbeenmet,theplanwillpay eacheligiblefamilymember'scoveredexpensesbasedonthe coinsurancelevelspecifiedbytheplan.

150%

Individual:$10,000 Family:$20,000

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PlanHighlights

InNetwork

OutofNetwork

CalendarYearOutofPocketMaximum l Onlytheamountyoupayforinnetworkcoveredexpensescounts towardyourinnetworkoutofpocketmaximum.Theamountyoupay foroutofnetworkcoveredexpensescountstowardbothyourin networkandoutofnetworkoutofpocketmaximums. l PlanDeductiblescontributetowardsyouroutofpocketmaximum. l Copaysandbenefitdeductiblescontributetowardsyouroutofpocket Individual:$5,000 maximum. Family:$10,000 l Mentalhealthandsubstanceabusecoveredexpensescontribute towardsyouroutofpocketmaximum. l Alleligiblefamilymemberscontributetowardsthefamilyoutofpocket maximum.Oncethefamilyoutofpocketmaximumhasbeenmet,the planwillpayeacheligiblefamilymember'scoveredexpensesat 100%

Individual:$30,000 Family:$60,000

PreExistingConditionLimitation(PCL)

Notapplicabletoanyoneunder19yearsold PCLappliestoanyinjuryorsicknessthatyouarediagnosedwithandreceivetreatment for,orincurexpensesforduringthe90daysbeforeyouareinsuredbythesebenefitsor youbeginaneligibilitywaitingperiod(whicheverisearlier).Pleaserefertoyourplan documentsforspecificdetails. Customerisresponsibleforcontacting CignaHealthcare.Subjectto penalty/reductionordenialfornon compliance. l 50%penaltyappliedtohospital inpatientchargesforfailuretocontact CignaHealthcaretoprecertify admission. l 50%penaltyforanyadmission reviewedbyCignaHealthcareandnot certified. l 50%penaltyforanyadditionaldays notcertifiedbyCignaHealthcare.

PrecertificationContinuedStayReviewPHS+Inpatientrequired Coordinatedbyyourphysician forallinpatientadmissions

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PlanHighlights

InNetwork

OutofNetwork
Customerisresponsibleforcontacting CignaHealthcare.Subjectto penalty/reductionordenialfornon compliance. l 50%penaltyappliedtooutpatient procedures/diagnostictestingcharges forfailuretocontactCignaHealthcare andtoprecertifyadmission. l Benefitsaredeniedforanyoutpatient procedures/diagnostictesting reviewedbyCignaHealthcareandnot certified.

PrecertificationContinuedStayReviewPHS+OutpatientPrior Authorizationrequiredforselectedoutpatientproceduresand diagnostictesting

Coordinatedbyyourphysician

Benefit
PhysicianServices PrimaryCarePhysician(PCP)OfficeVisit SpecialtyCarePhysicianOfficeVisit SurgeryPerformedinPhysician'sOffice AllergyTreatment/Injections AllergySerum Dispensedbythephysicianintheoffice

InNetwork

OutofNetwork
Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet

Youpay$50PCPcopay Youpay$50Specialistcopay Youpay$50PCPor$50Specialistcopay Youpaylesserof$50PCPor$50 Specialistcopayoractualcharge Planpays100%

Benefit
PreventiveCare

InNetwork

OutofNetwork

RoutinePreventiveCareAllAges l Includeswellbaby,wellchild,wellwomanandadultpreventivecare l Includescoverageofadditionalservices,suchasurinalysis,EKG,and Planpays100% otherlaboratorytests,supplementingthestandardPreventiveCare benefit. ImmunizationsAllAges

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Youpay50%coinsuranceafterplan deductibleismet

Planpays100%

Youpay50%coinsuranceafterplan deductibleismet

Cigna 2013

Mammogram,PAP,PSATests l CoverageincludestheassociatedPreventiveOutpatientProfessional Services. Planpays100% l Diagnosticrelatedservicesarecoveredatthesamelevelofbenefits asotherxrayandlabservices,basedonplaceofservice.

Youpay50%coinsuranceafterplan deductibleismet

Benefit Inpatient
InpatientHospitalFacility InpatientHospitalPhysician'sVisit/Consultation InpatientProfessionalServices l ForservicesperformedbySurgeons,Radiologists,Pathologistsand Anesthesiologists MultipleSurgicalReduction

InNetwork
Youpay30%coinsuranceafterplan deductibleismet Youpay30%coinsuranceafterplan deductibleismet Youpay30%coinsuranceafterplan deductibleismet

OutofNetwork
Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet

Multiplesurgeriesperformedduringoneoperatingsessionresultinpaymentreduction of50%tothesurgeryoflessercharge.Themostexpensiveprocedureispaidasany othersurgery.

Benefit Outpatient
OutpatientFacilityServices OutpatientProfessionalServices l ForservicesperformedbySurgeons,Radiologists,Pathologistsand Anesthesiologists

InNetwork
Youpay30%coinsuranceafterplan deductibleismet Youpay30%coinsuranceafterplan deductibleismet

OutofNetwork
Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet

ShortTermRehabilitation l Includesphysicaltherapy,speechtherapy,occupationaltherapy, pulmonaryrehabilitationandcognitivetherapy Youpay$50PCPor$50Specialistcopay Youpay50%coinsuranceafterplan l 60daysmaximumperCalendarYear deductibleismet l Therapydays,providedaspartofanapprovedHomeHealthCare plan,accumulatetotheoutpatientshorttermrehabtherapymaximum ChiropracticCare l 20daysmaximumperCalendarYear Youpay$50PCPor$50Specialistcopay Youpay50%coinsuranceafterplan deductibleismet

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Benefit OtherHealthCareFacilities/Services

InNetwork

OutofNetwork

HomeHealthCare (includesoutpatientprivatedutynursingdayswhenapprovedasmedically Youpay30%coinsuranceafterplan necessary) deductibleismet l UnlimiteddaysmaximumperCalendarYear l 16hourmaximumperday SkilledNursingFacility,RehabilitationHospital,SubAcuteFacility l 90daysmaximumperCalendarYear DurableMedicalEquipment l UnlimitedmaximumperCalendarYear BreastFeedingEquipmentandSupplies l Limitedtotherentalofonebreastpumpperbirthasorderedor prescribedbyaphysician. l Includesrelatedsupplies ExternalProstheticAppliances(EPA) l UnlimitedmaximumperCalendarYear Youpay30%coinsuranceafterplan deductibleismet Youpay30%coinsuranceafterplan deductibleismet

Youpay50%coinsuranceafterplan deductibleismet

Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet Youpay50%coinsuranceafterplan deductibleismet

Planpays100%

Youpay30%coinsuranceafterplan deductibleismet

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Benefit OtherHealthCareFacilities/Services

InNetwork

OutofNetwork

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit Physician'sOffice InNetwork Outof Network OutpatientFacility InNetwork Outof Network EmergencyRoom/Urgent CareFacility InNetwork Outof Network IndependentLab InNetwork Outof Network Youpay50% coinsurance afterplan deductibleis met InpatientHospital InNetwork Covered underplan's Inpatient Hospital benefit Covered underplan's Inpatient Hospital benefit Outof Network Covered underplan's Inpatient Hospital benefit Covered underplan's Inpatient Hospital benefit

LabandX ray

Planpays 100%

Youpay50% coinsurance Planpays afterplan 100% deductibleis met Youpay50% coinsurance afterplan deductibleis met $0perscan copaythen youpay30% coinsurance afterplan deductibleis met

Youpay50% coinsurance afterplan Planpays100% deductibleis met Youpay50% coinsurance $0perscancopay,plan afterplan pays100% deductibleis met

Planpays 100%

Advanced Radiology Imaging (MRI,MRA, CATScan, PETScan, etc.)

$0perscan copay,plan pays100%

Not Applicable

Not Applicable

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Physician'sOffice EmergencyRoom OutpatientProfessional Services (Radiologist,Pathologist,ER Physician) InNetwork OutofNetwork *Ambulance

Benefit Emergency Care

InNetwork

OutofNetwork

InNetwork

OutofNetwork

InNetwork

OutofNetwork

Youpay$50PCPor$50 Specialistcopay

Youpay$100pervisit(copay waivedifadmitted)

Youpay30%coinsuranceafter plandeductibleismet

Youpay30%coinsuranceafter plandeductibleismet

*Ambulanceservicesusedasnonemergencytransportation(e.g.,transportationfromhospitalbackhome)generallyarenotcovered

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PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit UrgentCare Physician'sOffice InNetwork OutofNetwork UrgentCareFacility InNetwork OutofNetwork OutpatientProfessional Services InNetwork OutofNetwork *Ambulance InNetwork OutofNetwork

Youpay$50PCPor$50 Specialistcopay

Youpay$50pervisit(copay waivedifadmitted)

Youpay30%coinsuranceafter plandeductibleismet

Youpay30%coinsuranceafter plandeductibleismet

*Ambulanceservicesusedasnonemergencytransportation(e.g.,transportationfromhospitalbackhome)generallyarenotcovered

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
InitialVisittoConfirm Pregnancy InNetwork OutofNetwork AllSubsequentPrenatalVisits, PostnatalVisitsandPhysician's DeliveryCharges InNetwork Youpay30% coinsurance afterplan deductibleis met OutofNetwork Youpay50% coinsurance afterplan deductibleis met OfficeVisitsinAdditionto GlobalMaternityFee (PerformedbyOB/GYNor Specialist) InNetwork OutofNetwork DeliveryFacility (InpatientHospital,Birthing Center) InNetwork Coveredsame asplan's Inpatient Hospitalbenefit OutofNetwork Coveredsame asplan's Inpatient Hospitalbenefit

Benefit

Maternity

Youpay50% Youpay$50 coinsurance PCPor$50 afterplan Specialistcopay deductibleis met

Youpay50% Youpay$50 coinsurance PCPor$50 afterplan Specialistcopay deductibleis met

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit InpatientHospitalandOtherHealthCareFacilities InNetwork OutofNetwork OutpatientServices InNetwork OutofNetwork

Hospice(providedaspartof Youpay30%coinsuranceafter Youpay50%coinsuranceafter Youpay30%coinsuranceafter Youpay50%coinsuranceafter HospiceCareProgram) plandeductibleismet plandeductibleismet plandeductibleismet plandeductibleismet

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PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit Family Planning Men's Services Physician'sServices OfficeVisit InNetwork Outof Network InpatientHospitalFacility InNetwork Outof Network Youpay50% coinsurance afterplan deductibleis met OutpatientFacility Services InNetwork Youpay30% coinsurance afterplan deductibleis met Outof Network Youpay50% coinsurance afterplan deductibleis met InpatientProfessional Services InNetwork Youpay30% coinsurance afterplan deductibleis met Outof Network Youpay50% coinsurance afterplan deductibleis met OutpatientProfessional Services InNetwork Youpay30% coinsurance afterplan deductibleis met Outof Network Youpay50% coinsurance afterplan deductibleis met

Youpay50% Youpay30% Youpay$50 coinsurance coinsurance PCPor$50 afterplan afterplan Specialist deductibleis deductibleis copay met met

Includessurgicalservices,suchasvasectomy(excludesreversals). Family Planning Women's Services Youpay50% coinsurance Planpays afterplan 100% deductibleis met Youpay50% coinsurance Planpays afterplan 100% deductibleis met Youpay50% coinsurance Planpays afterplan 100% deductibleis met Youpay50% coinsurance Planpays afterplan 100% deductibleis met Youpay50% coinsurance afterplan deductibleis met

Planpays 100%

Includessurgicalservices,suchastuballigation(excludesreversals). Contraceptivedevicesasorderedorprescribedbyaphysician. Youpay50% Youpay30% Youpay$50 coinsurance coinsurance PCPor$50 afterplan afterplan Specialist deductibleis deductibleis copay met met Youpay50% coinsurance afterplan deductibleis met Youpay30% coinsurance afterplan deductibleis met Youpay50% coinsurance afterplan deductibleis met Youpay30% coinsurance afterplan deductibleis met Youpay50% coinsurance afterplan deductibleis met Youpay30% coinsurance afterplan deductibleis met Youpay50% coinsurance afterplan deductibleis met

Infertility

Infertilitycoveredservices:labandradiologytest,counseling,surgicaltreatment,includesartificialinsemination,invitrofertilization,GIFT,ZIFT,etc. Unlimitedlifetimemaximum

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PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit TMJ, Surgical andNon Surgical Physician'sOffice InNetwork Outof Network InpatientFacility InNetwork Outof Network OutpatientFacility InNetwork Outof Network InpatientProfessional Services InNetwork Outof Network OutpatientProfessional Services InNetwork Outof Network

Notcovered Notcovered Notcovered Notcovered Notcovered Notcovered Notcovered Notcovered Notcovered Notcovered

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit Inpatient OutpatientPhysician'sOffice (includesindividual,grouptherapy mentalhealthandintensiveoutpatient mentalhealth) InNetwork OutofNetwork OutpatientFacility (includesindividual,grouptherapy mentalhealthandintensiveoutpatient mentalhealth) InNetwork OutofNetwork

MentalHealth
l l

InNetwork

OutofNetwork

Youpay30% Youpay50% coinsuranceafter coinsuranceafter Youpay$50copay plandeductibleismet plandeductibleismet

Youpay50% Youpay30% Youpay50% coinsuranceafter coinsuranceafter coinsuranceafter plandeductibleismet plandeductibleismet plandeductibleismet

Unlimitedmaximumpercalendaryear MentalHealthservicesarepaidat100%afteryoureachyouroutofpocketmaximum

PlaceofServiceYoupaybasedonwhereyoureceiveservices.
Benefit SubstanceAbuse InNetwork Inpatient OutofNetwork OutpatientPhysician'sOffice (includesindividualandintensive outpatientsubstanceabuse) InNetwork OutofNetwork OutpatientFacility (includesindividualandintensive outpatientsubstanceabuse) InNetwork OutofNetwork

Youpay30% Youpay50% coinsuranceafter coinsuranceafter Youpay$50copay plandeductibleismet plandeductibleismet

Youpay50% Youpay30% Youpay50% coinsuranceafter coinsuranceafter coinsuranceafter plandeductibleismet plandeductibleismet plandeductibleismet

Note:Detoxiscoveredundermedical l Unlimitedmaximumpercalendaryear l SubstanceAbuseservicesarepaidat100%afteryoureachyouroutofpocketmaximum

Pharmacy
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InNetwork

OutofNetwork

Cigna 2013

CignaPharmacyPlusthreetiercopayplan l GenericPush l SelfAdministeredinjectabledrugsincludesinfertilitydrugs l OralContraceptivesincluded l IncludesOralContraceptiveswithspecificproductscovered100% l Insulin,glucoseteststrips,lancets,insulinneedles&syringes,insulin pensandcartridgesincluded PharmacyDeductible l Appliestoinnetworkpharmacycosts l Retailpharmacycostscontributetothepharmacydeductibleand homedeliverypharmacycostdoesnotcontributetothepharmacy deductible.

Retail30daysupply Generic:Youpay$20 PreferredBrand:Youpay$40 NonPreferredBrand:Youpay$70 Homedelivery90daysupply Generic:Youpay$40 PreferredBrand:Youpay$80 NonPreferredBrand:Youpay$140

Retail Youpay50% Planpays50% HomeDelivery Notcovered

Individual$100 Family$200

IndividualNA FamilyNA

PharmacyClinicalManagementandPriorAuthorization l Yourplanissubjecttocertainclinicaleditsandpriorauthorizationrequirements ClinicalOutcomePrograms: l Includescomplexpsychiatriccasemanagement l Includesnarcotictherapymanagement SpecialtyPharmacyManagement: l ClinicalPrograms Priorauthorizationisrequiredonspecialtymedicationsbutquantitylimitsmayapply. TheracareProgram l MedicationAccessOption Retailand/orHomeDelivery

Definitions
CoinsuranceAfteryou'vereachedyourdeductible,youandyourplansharesomeofyourmedicalcosts.Theportionofcoveredexpensesyouareresponsiblefor iscalledcoinsurance. CopayAflatfeeyoupayforcertaincoveredservicessuchasdoctor'svisitsorprescriptions. DeductibleAflatdollaramountyoumustpayoutofyourownpocketbeforeyourplanbeginstopayforcoveredservices. OutofPocketMaximumSpecificlimitsforthetotalamountyouwillpayoutofyourownpocketbeforeyourplancoinsurancepercentagenolongerapplies.Once youmeetthesemaximums,yourplanthenpays100percentofthe"maximumreimbursablecharges"ornegotiatedfeesforcoveredservices. PrescriptionDrugListThelistofprescriptionbrandandgenericdrugscoveredbyyourpharmacyplan. TransitionofCareProvidesinnetworkhealthcoveragetonewcustomerswhenthecustomer'sdoctorisnotpartoftheCignanetworkandthereareapproved clinicalreasonswhythecustomershouldcontinuetoseethesamedoctor.

Dollars&Sense
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DOLLARS&SENSE:Easywaystodecreaseyouroutofpockethealthcareexpenses. Innetworkcare Usingdoctors,hospitalsandfacilitiesthatparticipateintheCignanetworkcansaveyoumoney.Inaddition,choosingCignaCaredesignatedspecialistsdoctors in19specialtieswhohavebeenidentifiedfortheirsuperiorperformanceinqualityandcostefficiencymaysaveyouevenmore.Youcanverifythatadoctoror facilityisinCigna'snetworkandlearnmoreabouttheCignaCaredesignationbycheckingthedirectoryonmyCigna.comorCigna.com,orbycallingthecustomer servicenumberonthebackofyourCignaIDcard.Cignaisopen24/7. Urgentcare (Averageurgentcarecentercost$131/AveragehospitalERcost$1,523) Manypeopleusetheemergencyroom(ER)forconditionsthatarenotseriousorlifethreatening.Usinganurgentcarecenteroryourdoctor'sofficeinsteadofanER cansaveyouhundredsofdollarsandprovidesthesamequalityofcareasanER.IfyouneedcareandarenotsureifyouneedtogototheER,speakwithyour doctororcallCigna's24hournurselineatthenumberonthebackyourCignaIDcardtodeterminethemostappropriatelocationforurgentcare. Conveniencecareorretailclinics (Averageconveniencecarecliniccost$61/AveragehospitalERcost$1,523) Conveniencecareclinicsprovidequickandeasyaccesstohighqualitytreatmentforcommonmedicalconditionswhenyourdoctorisnotavailable.Theseclinics arelocatedindepartmentstores,grocerystoresandpharmacies.Tolocateconveniencecareclinics,youcanchecktheDirectoryonmyCigna.comorCigna.com, orcallthecustomerservicenumberonthebackofyourCignaIDcard.Cignaisopen24/7. Laboratoryandpathologytests (AverageLabCorp/Questcost$9/Averageotherlabcost$24/Averageoutpatienthospitallabcost$48) Twoofthenation'slargestandmostprominentlaboratories,QuestDiagnostics,Inc.(Quest)andLaboratoryCorporationofAmerica(LabCorp),participateinthe Cignanetwork.Servicesattheselabscancost7075%lessandofferthesameorbetterqualitythanhospitallaboratories.Whenyouneedlabservices,discuss theseoptionswithyourdoctor.TofindthenearestQuestandLabCorplocations,checkthedirectoryonmyCigna.comorCigna.com. Radiologyservices(MRIorCTscan) (Averageindependentradiologyfacilitycost$591/Averageoutpatienthospitalcost$1,198) IfyouneedtohaveanMRIorCTscan,youcansavehundredsofdollarsbyusinganindependentradiologycenter.WhileCignacontractswithalltypesoffacilities thatprovideradiologyservices,usingindependentradiologycenterswillsaveyoumoney,withoutanydifferenceinquality.Discusslocationoptionswithyourdoctor. ForhelplocatingthemostcosteffectivefacilityinwhichtohaveanMRIorCTscan,youcanusethecostcomparisontoolsonmyCigna.comorcallthecustomer servicenumberonthebackofyourCignaIDcard. Colonoscopy,endoscopyorarthroscopy (Averagefreestandingsurgerycentercost$1,438/Averageoutpatienthospitalcost$2,821) Whenadoctorrecommendsacolonoscopy,GIendoscopyorarthroscopy,makesureyouknowyouroptions.Usingafreestandingoutpatientsurgerycenterfor theseproceduresinsteadofahospitalcanoftensavehundredsofdollars,whilemaintainingthesamehighqualityasahospital.Talkwithyourdoctoraboutoptions. Forhelplocatingthemostappropriatefacility,youcanuseourcostcomparisontoolsonmyCigna.comorcallthecustomerservicenumberonthebackofyour CignaIDcard. CignaHomeDeliveryPharmacy YoucansavemoneyandenjoyconvenienthomedeliverybyusingCignaHomeDeliveryPharmacyforyourprescriptionmedications.Youcangetuptoa90day supplyofyourmedication.

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Exclusions
What'sNotCovered(notallinclusive): Yourplanprovidescoverageformostmedicallynecessaryservices.Examplesofthingsyourplandoesnotcover,unlessrequiredbylaworcoveredunderthe pharmacybenefit,include(butaren'tlimitedto): l Cosmeticservices l Custodialandothernonskilledservices l Dentalcare,unlessduetoaccidentalinjurytosoundnaturalteeth l Experimental,investigationalorunprovenservices l Eyeglasslensesandframes,contactlensesandsurgicalvisioncorrection l Geneticscreenings l Nonprescriptionandantiobesitydrugs l Reversalofsterilizationprocedures l Servicesforaninjuryorillnessthatoccurswhileworkingforpayorprofitincludingservicescoveredbyworker'scompensationbenefits l Servicesprovidedthroughgovernmentprograms l Servicesthataren'tmedicallynecessary l Telephone,emailandinternetconsultationsintheabsenceofaspecificbenefit l Travelimmunizations l TreatmentofTMJDisorder l Treatmentofsexualdysfunction l Weightlossprograms l Hearingaids l Acupuncture l Obesitysurgeryandservices Theseareonlythehighlights Thissummaryoutlinesthehighlightsofyourplan.Foracompletelistofbothcoveredandnotcoveredservices,includingbenefitsrequiredbyyourstate,seeyour employer'sinsurancecertificateorsummaryplandescriptiontheofficialplandocuments.Ifthereareanydifferencesbetweenthissummaryandtheplan documents,theinformationintheplandocumentstakesprecedence.ThissummaryprovidesadditionalinformationnotprovidedintheSummaryofBenefitsand CoveragedocumentrequiredbytheFederalGovernment. "Cigna,""CignaHealthcare,""CignaCareNetwork,""CignaBehavioralHealth,""CignaChoiceFund,""CignaWellAwareforBetterHealth"and"myCigna.com" areregisteredservicemarks,and"CignaPharmacy,"CignaHomeDeliveryPharmacy,""CignaWellInformed,""CignaBehavioralAdvantage","YourHealth First"andthe"TreeofLife"logoareservicemarks,ofCignaIntellectualProperty,Inc.,licensedforusebyCignaCorporationanditsoperatingsubsidiaries.All productsandservicesareprovidedbyorthroughsuchoperatingsubsidiariesandnotbyCignaCorporation.SuchoperatingsubsidiariesincludeConnecticut GeneralLifeInsuranceCompany(CGLIC),CignaHealthandLifeInsuranceCompany(CHLIC),CignaBehavioralHealth,Inc.,TelDrug,Inc.,TelDrugof Pennsylvania,L.L.C.andHMOorservicecompanysubsidiariesofCignaHealthCorporationandCignaDentalHealth,Inc.InArizona,HMOplansareoffered byCignaHealthCareofArizona,Inc.InConnecticut,HMOplansareofferedbyCignaHealthCareofConnecticut,Inc.InNorthCarolina,HMOplansareoffered byCignaHealthCareofNorthCarolina,Inc.InCalifornia,HMOandNetworkplansareofferedbyCignaHealthCareofCalifornia,Inc.Allothermedicalplansin thesestatesareinsuredoradministeredbyCGLICorCHLIC."CignaHomeDeliveryPharmacy"referstoTelDrug,Inc.andTelDrugofPennsylvania,L.L.C.

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